Qualify for government subsidy: become a(n involuntary) unionized government employee

 Next up: doctors, section 8 housing owners, ????? Grocery stores, drug stores???

A year ago in December, Ms. Berry and more than 40,000 other home-based day care providers statewide were suddenly informed they were members of Child Care Providers Together Michigan—a union created in 2006 by the United Auto Workers and the American Federation of State, County and Municipal Employees. The union had won a certification election conducted by mail under the auspices of the Michigan Employment Relations Commission. In that election only 6,000 day-care providers voted. The pro-labor vote turned out.

Many of the state's other 34,000 day-care providers never even realized what was going on. Ms. Berry tells us she was "shocked" to find out she was suddenly in a union. The real dirty work, however, had been done when the state created an "employer" for the union to "organize" against.
Of course, Michigan's independent day-care providers don't work for anybody except the parents who were their customers. Nevertheless, because some of these parents qualified for public subsidies, the Child Care Providers "union" claimed the providers were "public employees."
Michigan's Department of Human Services then teamed with Flint-based Mott Community College to sign an "interlocal agreement" in 2006 establishing a separate government agency called the Michigan Home Based Child Care Council. This council was directed to recommend good child-care practices—and not coincidentally, to serve as a "public employer." Although the council had almost no staff, no control over the state subsidies and no supervision of the providers' daily activities, it became the shell corporation against which the union could organize.
Thus the state created an ersatz employer and an ersatz "bargaining unit" against which what was essentially an ersatz union could organize.
Today the Department of Human Services siphons about $3.7 million in annual dues to the union—from the child-care subsidies. The money should be going to home-based day-care providers—themselves not on the high end of the income scale. Ms. Berry now sees money once paid to her go to a union that does little for her. She says she is "self employed and wants nothing to do with the union."

Aristotle ethics, RFK, and health care reform

The Wall Street Journal's daily newsletter by James Taranto, The Best of the Web Today, debunks a quote floating around the Internet to support the "right" to health care paid for by government. The blurb has been attributed to a translation from the writings of Aristotle, a translation from the original Greek by Robert F. Kennedy.

Unfortunately, the first reference to the quote is from 10 years after Senator Kennedy died, is credited to someone else, and the original cannot be found in the existing works of Aristotle.

From an article by Edmond Pellegrino, the last chairman of President Bush's President's Bioethics Council, written in 2008:

In attempts to establish the provenance of the text in question we have conducted an extensive search for its source and original wording. We have not been able to locate it. Our initial curiosity was aroused by several things, including that rights language did not seem to have the Aristotelian context, and health care, as such, was not included in Aristotle's works. We searched Nicomachean Ethics and Eudemian Ethics, and the Magna Moralia without successfully locating the quote. Nor could we find it in other of works of Aristotle: On Length and Shortness of Life, De Anima, Economics or the Fragments. "Rights" language certainly would stick out in Aristotle's virtue-based ethics.

That article by Dr. Pellegrino is available in pdf, here, thanks to the WSJ and Georgetown Bioethics.

Playing doctor with the White House

Who’s playing doctor with the White House: Another example of the lack of openness in the dealings of the Obama Administration

(Informed consent blurb: Organizing for America, etc., along with all the White House websites, are collecting data including email and other information from everyone who visits or contacts their sites. I got a couple of those emails from David Axelrod last month.

Don't worry - they already have my data. I used to email President Bill Clinton at least once a month and ask him to resign for the sake of our daughters – they are about the same age - because he'd set the women's movement back 50 years. He never answered. However, it occurs to me now that maybe that's why I was named to the Bush Administration's National Advisory Committee on Violence Against Women.)

On Thursday, September 17, 2009, I was web-surfing and searching Google news hits on the September 12th March on Washington and health care reform when I found information about a conference call between "Doctors for America," the White House "Office of Public Engagement" and doctors like me who somehow found out about the conference call.

I called in, but wasn't called on to ask my questions, so I re-wrote them as an essay (see below) and emailed it to info@drsforamerica.org I'm also sending the essay to the White House OPE.

When I started writing up my notes from the call, it finally occurred to me that – even though there was no attempt at disclosure - there might be a connection between "Drs for America," "Organizing for America" (whose website address is still "http://www.barackobama.com/ ," the same url once used by - and the remains of - “Obama for America,” the Barack Obama campaign machine.

I was slow to catch on, but I was right: The leadership at Doctors for America is made up of nearly the same roster of men and women who, in 2008, were the leadership of “Doctors for Obama” in 2008. Common names are Vivek Murthy, MD MBA, Mandy Krauthamer, MD MPH, Nikhil Wagle, MD, Alex Blum, MD, and Jay Bhatt, DO MPH

And, I was wrong: there’s a disclaimer at the bottom of the “Doctors for Obama” leadership page that says “Not affiliated with Obama for America.” (Yeah, right.)

In fact, former Obama Administration transition chief John Podesta's “Center for American Progress” funds the group :

May 04, 2009
'Doctors for America' launches

This may not wind up being decisive in the health care fight, but the organizing gap between the two sides continues to widen.
Sen. Max Baucus and the Center for American Progress Action Fund are announcing a new group on a conference call later this morning: Doctors for America, which is a reincarnation of Doctors for Obama, an arm of the Obama campaign that boasted more than 10,000 members.
The question of patients' relationships with their doctors is always a flashpoint in debating changes to the health care system, so doctors are often particularly credible messengers.
Today they'll "release new reports detailing the depth and breadth of America's health care crisis and announce a new effort to amplify physicians' voices in support of health care reform," according to the advisory.
By Ben Smith 11:07 AM

Here's the bio on the President and Co-founder, Vivek Murthy, MD MBA, at the Center for American Progress website:

Vivek Murthy is an internal medicine physician at Brigham and Women’s Hospital and an Instructor at Harvard Medical School. He received his undergraduate degree in Biochemical Sciences from Harvard University, his MD from the Yale School of Medicine, and his MBA from the Yale School of Management. He completed his residency training in Internal Medicine at Brigham and Women’s Hospital. Vivek is the co-founder of VISIONS and the Swasthya Project, international health non-profit organizations focused on HIV/AIDS education and women’s health, respectively. He is also the co-founder and chairman of Epernicus, LLC a web-based professional networking service for individual researchers and scientific institutions. Vivek’s past research has focused on the participation of women and minorities in cancer clinical trials; his current research interests include physician satisfaction and burnout. During the 2008 presidential campaign, Vivek served as a member of the Obama Health Policy Advisory Committee and the Obama New England Steering Committee.

Notes on the Conference Call

I couldn't catch all the names and I am not very good at telling who was speaking, but did try to take some notes from the opening statements. The quotations are the actual words of the speakers, the rest is my own interpretation and from memory.

The moderators talked about the "public option" as though it's a done deal and strongly pitched it as just a way to provide health care for people who have lost their insurance.

We were told that everyone will be required to have insurance, and that businesses will be asked to "chip in their part."

The White House has a plan to fix the SGR that has been pushed off over and over. In fact, there are plans for a “complete reform of the physician payment system.” without incentives for doing more procedures.

The President has given instructions to begin the medical liability demonstration projects to find a way to decrease defensive medicine while "mitigating risks to patients."

We were told that we are closer than we've ever been to health care reform this year.

The moderators were surprised by the second doctor who said he was from the former Soviet Union and that the public option would soon become the only option. They were adamant that the public option is not a pathway to single payer. (And besides, we all know that being paid by and regulated to the teeth by the government is not at all like working for the government.)

Later, one of the docs who called in asked specifically about the news stories that the public option was finished and the White House representative reminded us that the legislation is not written, yet. He was adamant that we shouldn't rule the public option out and that we should advocate with our patients and fellow doctors for that option.

One doctor asked about the effect on doctors with concierge or boutique practices and the other doctors who "opted out." The answer from one of the men was that these practices were just a reaction to cash pay patients who couldn't afford insurance.

There was a lot of excitement about one doctor's suggestion that doctors be required to give two years to a sort of National Healthcare Workforce. And huffy about the shortage of doctors that a Massachusetts doc reminded them that they'd have if all the uninsured were suddenly looking for primary care.

The woman naturopath was reassured that naturopathic primary care doctors would be evaluated by the same evidence based medicine that the traditional docs were judged by.

My letter to Doctors for America and the White House Office for Public Engagement

I’m Beverly B Nuckols, MD, the National chair of the Family Medicine Section of the Christian Medical Association as well as a member of the AMA, the Texas Medical Association and the American Academy of Family Physicians. I'm not officially representing the above, but I believe that my opinions are shared by a large number of doctors.

Many of my colleagues and I see the Patient Centered Medical Home plans, the protocols at Mayo and other medical centers that have been praised are attempts to model a bureaucratic form of practice for large practices so that they can do what the family doctor does every day.

My experience is that government bureaucracy is not only more restrictive and punitive than private insurers, the clout of the Federal government results in undesired UNINTENDED consequences all across the board. Doctors used to be the good guys, but now we feel as though we are assumed to be guilty of abuse of the system, largely due to Federal legislation and regulation.

These result in time and money spent on our futile attempt to keep up with Medicare regulations in order to avoid charges of fraud, abuse and waste. For instance: HIPPA, National Provider Identification numbers, bullet points and check boxes, E & M’s, procedure and diagnosis codes and qualifiers that change each year, and a whole alphabet soup of regulators.

In addition, government cost control attempts in the '90's actually limited the numbers of graduate medical slots, while encouraging sub specialty growth in relation to numbers of primary care doctors.

Making it all worse is the fact that under current Medicare payment schemes, Family Doctors who provide the same services as sub-specialists are paid less by Medicare.

Like the laws and regulations in the past, this year's “reform bills” and proposals are overly complicated and try to guarantee too much: school based clinics, nutrition data on menus and buffet lines, an overhaul of the federal income tax code, new lists of “enhanced penalties,” taxes, fines and the mixing of all of the above abuses with an overhaul of the Federal Income Tax.

Today’s announcement about the study of liability makes me worry that our Texas laws concerning tort reform will be over come by Federal inertia and interference.

1. Why not just look at Texas’ experience with tort reform rather than wasting time and money on new studies?

2. Is it possible to make the legislation smaller in scope so that it is focused on providing help for those patients and families who cannot afford or access medical care?

3. What plans are there to ensure training and sufficient payment for family physicians and other primary care doctors who are in the best position to coordinate care for our patients in the "Medical Home?"

Edit: added this 4th question that I believe I sent to Doctors for America:

4. Could the fines and mandates be replaced with tax incentives, removal of restrictions on Health Savings accounts, return of the major medical plans and the removal of the barriers preventing patients from owning their own health care insurance?

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Myth: doctors take out tonsils needlessly

Then, there's the charge that doctors will needlessly take tonsils out. First, it's unlikely that your Family Physician or Pediatrician does surgery. Second, I don't think the ENT's are getting paid for these anymore, unless they jump through hoops to prove that they're not over-doing it.

AP: In trying to rally support for health care overhaul, Obama described a patient who sees a physician for a sore throat, or a parent who brings in a child with a sore throat.

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out,'" Obama told a prime-time news conference.

The president added: "Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change — maybe they have allergies. Maybe they have something else that would make a difference."

Video and here.

Obama Press Conference Transcript

The transcript of the press conference is on line at the Washington Post.

However, if you want an annotated version, try this blog.

Force Medicare "reform" without proof that it will work?

The Washington Post reports on the latest findings of the "Medicare Payment Advisory Commission" (MedPAC) today. According to the WaPo, this is a "commission that advises Congress on the federal medical program for older Americans."

In other reports, there is mention that President Obama plans - at the same time - to cut Medicare and Medicaid funding by over $900 Billion dollars, to somehow expand the numbers of Americans who are given "guaranteed health care" under some government "public plan," and to pay for any expansion by taxing insurance benefits given by employers.

And it all has to be done in the next two weeks:

For months, Obama remained on the sidelines of the health-care debate because "he felt it was important to not be too proscriptive," Axelrod said in an interview. "Now we're into a different phase, where decisions are being made very quickly, so it's time to weigh in to a greater degree."

The Obama strategy, articulated in the speech here and in a series of private meetings, is to present each major stakeholder with an enticement in return for a bit of sacrifice.

Again, there's mention of "accountable care organizations," and how to force doctors into them. This time, we do learn that coercion will be necessary to form these organizations and that there's evidence that these sort of interventions don't save money or improve the health care of patients caught up in the schemes. In fact, some of these interventions are now considered wasteful and the first place to cut:

To illustrate what it might take to save Medicare, the commission describes how primary-care doctors, specialists and hospitals could be reorganized into "accountable care organizations" whose members would receive bonuses if the organizations met quality and cost targets. To ratchet up the incentives, health-care providers that fail to meet cost and quality targets could be penalized, the report says.

Even then, any projected savings would be highly uncertain, the report says. What is certain is that Medicare cannot maintain its current trajectory, it adds:

"If current spending and utilization trends continue, the Medicare program is fiscally unsustainable. . . . Part of the problem is that Medicare's fee-for-service payment systems reward more care -- and more complex care -- without regard to the quality or value of that care."

The report underscores the challenges facing President Obama and Congress as they seek to overhaul the health-care economy. The administration has put a spotlight on what it considers wasteful spending, but it has offered sparse details as to how it would change the incentives that produce the waste.

The report identifies some areas that are ripe for savings. MedPAC estimates that the government is paying private Medicare health plans -- which were supposed to save the government money -- much more than it should. In addition, the government could save money by adopting a more streamlined approval process for "follow-on biologics" -- products that imitate biotech treatments already on the market.

Getting doctors to join accountable care organizations may require pressure, MedPAC Executive Director Mark E. Miller told reporters: "If you want people to voluntarily organize, you may want to make sure that the current system isn't as pleasant a place to be."

The model for accountable care organizations resembles that of large, tightly managed physician groups, practices that have been the subject of demonstration projects, and Medicare's experience with those offers limited encouragement, according to the report. Measurable quality improved in the areas of care monitored, such as for diabetes and congestive heart failure. But "whether the demonstration has actually generated savings for the Medicare program is debatable," the report says.

Policymakers hope that money can be saved by better coordinating care. But, according to the MedPAC report, Medicare pilot programs intended to coordinate care for patients with chronic diseases -- programs that involved insurance companies and other private groups -- generally achieved modest quality improvements. Most of the programs cost Medicare more money than it would have spent without them, the report says.

Senate defeats Republican SCHIP pro-life measure

Senator Martinez from Florida introduced an amendment to the Senate Bill concerning the children's health insurance bill that would have prohibited tex money going to non-government organizations in other countries and used to promote abortion, lobbying foreign governments to change their laws to accept abortion, and which would give those organizations more money to perform abortions.

This amendment would have placed into law the "Mexico City Policy" that President Obama overturned on Friday, January 23, 2009.

The vote went pretty much along party lines, with the exceptions of Republican Senators Collins and Snowe of Maine, Senator Spectre of Pennsylvania and Senator Mulkowski of Alaska. One Democrat, Senator Nelson of Nebraska, voted in favor of the prolife amendment. (Thanks to LifeNews for reporting the votes.)

The Senate version will allow families that exceed 400 times the Federal poverty limit t0 $88,000 and, in some cases, with incomes over $100,000, per year.

For more on the SCHIP Bill, see the Associated Press' "GOP fails to limit children's health program."

Democrats want to more than double spending on SCHIP. President Barack Obama has urged Congress to quickly send him a children's health bill that he can sign into law. The House has already passed a bill comparable to the one before the Senate.

Republicans offered an alternative approach through an amendment sponsored by Sen. Mitch McConnell, R-Ky. McConnell argued that his amendment focused more on helping low-income families and did not rely on tax increases to pay for the additional health spending. His amendment also would not allow federal funding to extend health coverage to children of newly arrived legal immigrants, as the Democratic bill allows.

Insurers, you go first

You did know that due to the Social Security Act and the Patriot Act your medical records can be viewed and copied by anyone who claims to be an agent of the Secretary of Health and Human Services, didn't you? Or that those same agents write their own subpoenas? (The best reference is this ACLU webpage, although most of the regulations were there in a weaker form before the Patriot Act.)

Health insurers - the American Health Insurance Plan group and Blue Cross/Blue Shield - said that they would begin covering everyone regardless of pre-existing conditions if the government will mandate the purchase of their products and subsidize Medicaid and SCHIP. And so grows the government ownership of health care.

From what I've seen of mandatory auto insurance, prices don't go down when the government forces everyone to buy a certain product. I don't believe in government mandates as a rule and haven't been favorably impressed with the way government interference in health care, with the creation of HMO's, ERISSA, and the invasion that has resulted in our current draconian Medicare rules and regulations.

Not to mention $2 Billion dollar stock option bonuses and $125 Million dollar salaries, such as those given to William McGuire by United Health Care in the past and the $13 million to $15 million salary of his successor in 2006 and 2007. (For a look at the compensation of the big companies, click on the names of companies at this page.)

I do believe that insurers abuse their ability to refuse or limit coverage and increase fees due to prior conditions. The industry should be able to evaluate the effect of removal of pre-existing conditions by looking at the history of the insured in States like Texas, which do not allow such limitations for most people covered by employers' health insurance. Let us see those numbers and facts and demonstrate your trustworthiness before we even consider using government laws to increase your customer base.

From the press release of the American Health Insurance Plan group:

Health plans today proposed guaranteed coverage for people with pre-existing medical conditions in conjunction with an enforceable individual coverage mandate.

Under the new proposal, health plans participating in the individual health insurance market would be required to offer coverage to all applicants as part of a universal participation plan in which all individuals were required to maintain health insurance.

Health plans also said that premium support for moderate-income individuals and broad spreading of risk was necessary to promote affordability and maintain premium stability in the individual health insurance market.

To ensure that all Americans can access coverage, health plans also reiterated their long-standing support for making eligible for Medicaid every uninsured American living in poverty and strengthening the Children’s Health Insurance Program.

In the interest of showing good will, let the sellers go first.

I'd rather see a law allowing various levels of coverage, including support for Health Savings Accounts (rather than the ridiculous limits on numbers that we currently have) and encouraging more major medical and high deductible plans.

Healthcare lottery

When you buy a lottery ticket, do you choose the cash option with its immediate payout of half the winnings or do you choose the payment of the full amount, doled out over 20 years?

I've found this question to be a good way to help other people understand the difference between conservativism and those who think that someone else can take care of them or the "totalitarian mamas" who believe that they can take better care of us than we could ourselves and for our own good. (Of course, some Conservatives tell me don't gamble, so they never buy lottery tickets.)

It's amazing how many people tell me that they always buy the "cash option." Some say they worry that their families wouldn't get anything if they die before the 20 years is up. Some tell me that they believe they can manage and invest the money to earn more than they would if they wait out the smaller payments. A few tell me that they would rather not have all the money at one time, preferring the guaranteed income over the years or fearing blowing the money.

The latter group never understands why I suggest that their health insurance should be something that they own and control, rather than something doled out by government and their employers.

A "right" is something that we each have without conditions and which we can call on society and government to enforce or punish if someone infringes that right. The right to life is actually the right not to be killed. We expect our fellow citizens to protect us through providing armies and law enforcement, a militia and by allowing self-defense. If another person infringes our right not to be killed, we expect society to punish him.

Last night, Democratic Presidential Candidate Barack Obama stated that health care is a right. I strongly disagree.

"Health" and "health care" are difficult terms to define. Instead of people and their actions, health is threatened by disease, age and injury. If I'm not well, how will society protect my health - and who or what will be held responsible as I inevitably age? If I have a "right" to health care, then I want everything possible to maximize my health. Rights can't be rationed.

What we're really talking about is health care funding. Funding certainly can be rationed. Take a look at Medicare, Medicaid, and the Veteran's Administration.

These systems work fairly well most of the time. However, they rely on limiting the costs of health care. The limitations fail when demand for cutting edge, expensive treatments or emotional arguments override them. That's why Medicare won't pay for a tetanus shot after a dirty wound, but will pay for annual physicals, screening mammograms and prostate specific antigen tests, although there's no evidence that these prolong life.

Or why Oregon Health sends notes telling patients that they won't pay for cancer treatments, but they will pay for assisted suicide.

For more on this subject, here's another opinion.

Dr. Nurse? Why not just Doctor?

Get ready for Dr. Nurse, who will call himself/herself "Doctor," but who, after 4 year bachelor's degree in nursing, has gone to the Doctor of Nursing school for two years with a one year internship -- that's compared to the 4 years of college, 4 years of medical school, followed by at least 3 years of residency that Family Physicians, Pediatricians and Internal Medicine docs devote to training..

The Wall Street Journal reports (please let me know if you can't access this page) that the National Board of Medical Examiners will begin testing these "DrNP" candidates this fall.

From the Wall Street Journal:

As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

So,the supposed reasoning behind the new doctorate is this shortage of primary care doctors. That shortage has been artificially encouraged by all sorts of federal interventions. For some reason, no one's considered paying Family Doctors more!

Instead, there are schemes to divide and re-divide the Medicare "Pie." There are the rural health clinics, which are paid more by Medicare and Medicaid than your local family doctor, pediatrician or internal medicine doc for seeing the same patients. In order to qualify, the clinic -- get the distinction, there, not the doctor, but who ever it is that owns the clinic and contracts with doctors and hires the rest of the staff - must hire at least one "mid level practitioner" to see patients. They can't hire a doctor to do the same work and/or for the same money -- they must hire a Physician Assistant or Nurse Practitioner.

As the article notes, the main reason for the loss of primary care physicians, however, is the low pay for the thinking part of what we do, compared to the procedures of specialists, such as all the varieties of surgeons, urologists, gynecologists and gastroenterologists. We analyze, examine and determine treatment or treatment change, resulting in "Evaluation and Management" visits. Rather than the codes used for procedures, the E&M visits are divided into levels of payment based on a set of check lists and diagnoses. The money from Medicare - followed closely by the insurance companies - has consistently shifted from the office visits toward the procedures.

Needless to say, the smart medical students -- or at least the ones more interested in money than in your family history, living arrangements and whether Junior ate his peas and carrots will become interventional sub-specialists, not a Family Physician or Pediatrician.

A few years ago, Medicare payments increased for home health agencies, which encouraged RN's and LVN's to leave the hospital. Medicare quit paying your family doc to "scrub in" with the general surgeon or orthopedist as an assistant during your gall bladder surgery, colon resection or hip replacement. But, they did pay the surgeon enough to justify the hiring of a nurse practitioner or physician assistant. And studies said there was no difference or even better outcomes, since the "team" worked better in the Operating room and the peri-surgery procedure became more efficient.

(Of course, the NP or PA won't be available to your wife or kids for questions next week, and won't watch the effect of your new level of activity on your blood pressure or diabetes. And your family doctor may no longer even know that she should, since she won't even find out about the surgery until your next visit or hospitalization. But that has nothing to do with the outcome of the surgery, right?)

The increase of Federal funding for Nurse Practitioners has exacerbated the loss of good RN's and LVN's - leading to more of the Federal pie going to nursing schools. And the DrNP will probably have the same effect. The WSJ article mentions the lack of faculty in the nursing schools. The funding will have to come out of the Medicare and Federal "pie."

However, what patients need to consider is whether the DrNP training can truly accomplish the same training in 3 years that our Medical Schools can do in 5 to 7 years. Some have said that mid levels can handle 80% of what doctors do.

It's that 20% that is the difference between knowing what you don't know and planning for the 2 AM crisis.

Secretary of Health Supports Conscience

Secretary of Health Michael O. Leavitt has stepped up to protect the right of conscience and conscientious refusal, specifically in the right not to be forced to commit or be complicit in abortion and other forms of killing. The Secretary has sent a letter to the President of the American College of Obstetrics and Gynecology warning about a possible conflict with Federal anti-discrimination rulings secondary to ACOG's Ethics Statement #385. (that's a pdf)

See the LifeEthics post explaining the origin of the conflict, here.

The American Association of Pro-Life Obstetrics and Gynecology, alerted us to the Press Release sent out by the HHS, most likely due to the fact that the ACOG Ethics Committee is meeting Monday and Tuesday, March 17 and 18.

Here's the news item:

FOR IMMEDIATE RELEASE Contact: HHS Press Office
Friday, March 14, 2008 (202) 690-6343

HHS SECRETARY CALLS ON CERTIFICATION GROUP TO PROTECT CONSCIENCE RIGHTS

Unless changes are made, physicians could be forced to refer patients for abortions even if it violates their conscience

Health and Human Services Secretary Mike Leavitt today expressed disappointment in a new policy put forth by the American College of Obstetricians and Gynecologists (ACOG).He also called on the American Board of Obstetrics and Gynecology (ABOG) to reject this policy and protect the conscience rights of physicians.

In a letter sent to ABOG Executive Director Dr. Norman Grant today asking for clarification, Secretary Leavitt notes, "It appears that the interaction of the [ABOG Bulletin for 2008 Maintenance of Certification] with the ACOG ethics report would force physicians to violate their conscience by referring patients for abortions or taking other objectionable actions, or risk losing their board certification."

In particular, the Secretary expressed concern that enforcement of this ACOG policy by certain federally-funded entities would violate federal laws against discrimination.

Secretary Leavitt continues, "As you know, Congress has protected the rights of physicians and other health care professionals by passing two non-discrimination laws and annually renewing an appropriations rider that protect the rights, including conscience rights, of health care professionals in programs or facilities conducted or supported by federal funds."

The full text of Secretary Leavitt's letter appears below:

Norman F. Gant, M.D.,
Executive Director
The American Board of Obstetrics and Gynecology
2915 Vine Street
Dallas, TX 75204

Dear Dr. Gant:

I am writing to express my strong concern over recent actions that undermine the conscience and other individual rights of health care providers. Specifically, I bring to your attention the potential interaction of the American Board of Obstetrics and Gynecology's (ABOG) Bulletin for 2008 Maintenance of Certification (Bulletin with a recent report (Opinion Number 385) issued by the American College of Obstetricians and Gynecologists (ACOG) Ethics Committee on November 7, 2007 entitled "The Limits of Conscience Refusal in Reproductive Medicine".

The ACOG Ethics Committee report recommends that in the context of providing abortions, "Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive service that patients request." It appears that the interaction of the ABOG Bulletin with the ACOG ethics report would force physicians to violate their conscience by referring patients for abortions or taking other objectionable actions, or risk losing their board certification.

As you know, Congress has protected the rights of physicians and other health care professionals by passing two non-discrimination laws and annually renewing an appropriations rider that protect the rights, including conscience rights, of health care professionals in programs or facilities conducted or supported by federal funds. (See 42 U.S.C. § 238n, 42 U.S.C. § 300a-7, and the Consolidated Appropriations Act, 2008, Pub. L. No. 110-161, 121 Stat. 1844, § 508). Additionally, threats to withhold or revoke board certification can cause serious economic harm to good practitioners.

I am concerned that the actions taken by ACOG and ABOG could result in the denial or revocation of Board certification of a physician who -- but for his or her refusal, for example, to refer a patient for an abortion -- would be certified. These actions, in turn, could result in certain HHS-funded State and local governments, institutions, or other entities that require Board certification taking action against the physician based just on the Board's denial or revocation of certification. In particular, I am concerned that such actions by these entities would violate federal laws against discrimination.

In the hope that compliance of entities with the obligations that accompany certain federal funds will not be jeopardized, it would be helpful if you could clarify that ABOG will not rely on the ACOG Ethics Committee Report, "The Limits of Conscience Refusal in Reproductive Medicine" when making determinations of whether to grant or revoke board certifications.

Thank you very much for your assistance in this matter.

Sincerely,

Michael O. Leavitt
cc:
Kenneth Noller, M.D.

The American College of Obstetricians and Gynecologists

Medicare Pie Cut Thinner

Think of the money that Medicare pays doctors for seeing patients as though it's a pie called the "Sustainable Growth Rate." This pie is not going to get bigger unless Congress cooks some more pies by New Years. Otherwise, when more patients join Medicare and more pieces are needed next year, we will have to cut the pieces that doctors are paid each time we see a patient into smaller and smaller pieces.

I wimped out: I closed my office in 2003 because I saw the costs of the requirements for medical reporting and "privacy" coming and I figured that I could work part time for other people and make more money than I was making as a solo doc. (And I hate the business part of medicine.) I'm not sure how many others are making the same decision, but we often read about "boutique" practices and docs who won't take Medicare or new Medicare patients. Have you noticed how many doctors in your town are adding things like Botox shots, laser therapy and other cash-pay services?

Medicare will cut doctors' reimbursement by 10% in January if Congress doesn't act before the end of the year. This cut is separate from the Veterans Administration, Medicaid and SCHIP funding and is written into the current law. Since many doctors have contracts with insurance companies that pay based on Medicare, the cuts will go even deeper.

If you don't understand the impact that this cut will have, ask the next person you meet who is over 65 years old whether they had to change doctors when they became Medicare eligible. Ask them whether they have any choice other than to use Medicare and how hard it is to get in to see their doctor.

As I've said before, get ready for it to become even harder.

10 years ago, financial advisers told us that Family Physicians shouldn't have more than 20% of our patient population mix made up of Medicare patients if we wanted to stay in business. Since that time, most doctors have worked harder to be more efficient and have cut out any costs in the office that we don't need. My colleagues cannot afford a 10% cut in pay, while all of our costs continue to go up.

Primary care docs are paid about $160 per hour for office visits by Medicare. We are more likely to see the patients who have 5 or 6 diagnoses, 10 or 12 medicines to straighten out, and who bring in a family member to each visit. These patients take time. If the payment goes down to $155 per hour, most doctors will not be able to afford the cut.

In order to earn that money, we need the office and furniture, utilities, supplies for the patient room and office staff, at least a couple of staff members to check patients in and assist us, someone to answer the phones, those phones, refrigerators for medications, someone to handle the billing and banking, and all of the fees and insurance that normal businesses handle, like property taxes, slip and fall insurance, fire insurance, employee tax to the State, property tax on the building, furniture and supplies, and unemployment insurance, etc.


Then, we have malpractice insurance, professional dues to the County Medical Society and most likely our State and national AMA dues in order to remain "Board Certified," State licensing fees, DEA licenses from both the State and Federal systems, hazardous waste disposal fees, CLIA (office lab) fees, and the fees to keep our computer systems that are increasingly mandated by law if we want to be paid the full $160. The new electronic medical records can cost as much as $30-$40,000 per doctor up front and several hundreds to thousands per month.

In addition to these costs, Medicare requires the highest level of reporting, risk and red-tape. This year, there was a planned delay of payment from the Federal government for 2 weeks at the end of October built into the Federal budget to make it appear balanced. There were also unplanned delays when doctors began using the new National Provider Numbers phased in this year as part of the Medicare laws. (A lot of that expensive computer software in the office, at the insurance companies, and at the Center for Medicare and Medicaid Services couldn't handle the numbers.)

Now do you see why I hate business?

For more information and history, read this article or watch this video from the Texas Academy of Family Physicians.

Please consider calling your Representative to the House, your two State Senators, and the White House and ask them to protect Medicare payments to doctors.

Varied and deep rooted (cost of health care)

I'd just add a few observations to the New York Times editorial (free registration required) on the cost of health care in the US.

I'm a big proponent of making patients responsible for more of their health care costs. Health Savings Accounts, long term care insurance, and even deductibles are good ideas. I would also add that the vast majority of the people on Medicaid and public assistance could do some sort of public service work in payment for their health care. (Medicare, disability, and veteran's health care has been paid for already.)


I especially like the idea that primary care should be emphasized. How about *paying* doctors to do it instead of ensuring that we lose money for every Medicaid and Medicare patient we see?

And they don't mention some of the problems that I see:

1. Over the counter medicines that probably aren't needed in the first place and don't do what they are believed to do. Did anyone notice that the baby cold medicines are not useful and no longer standard of care? And please don't get me started on homeopathy - I'll irritate a couple of million of my readers if I go on about the useless idea that a substance diluted millions of times in water can't do anything.

2. Botox, cosmetic surgery, and beauty treatments - Do these services, when provided by a physician go into that giant number?

3. The hidden costs of school-based health care and the need for "notes" from doctors for school and work. I doubt that many people are aware of how much of Medicaid money is spent on "mainstreaming" and on learning disabilities in our school systems. I'm sure that few would understand the pressures that doctors face to provide the testing, medications, and follow up required to get mom back to work after the baby is too sick for daycare or school, for the note for the Tuesday patient who says they had food poisoning on Monday, or for the demand from a school or from the parents to get the 7 year old tested for a learning disability for all sorts of reasons.

4. Salaries and perks for insurance big wigs that could pay for the healthcare system of a couple of nations. United Healthcare, which threatens to swallow up every insurance company in the nation, has paid at least $120 Million dollars to its CEO for at least 10 years.

5. I don't want it to go away -- but -- Medicare pays for quite a bit of the research and medical education in the country. We need to see this research and the doctors, medicines and treatments that come from these funds as the valuable commodity they are and quit dinging "health care costs" for it.

Statistics and politics

Statistics are easily mistakenly used and manipulated. Rudy Guiliani is under attack due to statistics that he quoted in a political ad running in New Hampshire . He spoke about the odds of surviving prostate cancer, contrasting the medical systems in the United States and in the United Kingdom. I saw a link to an article titled, "Guiliani learns math is hard" (I couldn't get that link to work and had to do a search) when I was linking to the American Journal of Bioethics for yesterdays' post.

The search at the Washington Post led me to Eugene Robinson's opinion column (free registration required), which featured "Related" links to another op-ed by Libby Quaid of the AP and an AP "Fact Check" article that is almost identical to the Quaid piece. Robinson also links to the article that the Mayor's statisticsare said to have from.

Both Quaid's op-ed and the "Fact Check" article state that 15 out of 100,000 "people die from prostate cancer in the UK vs. 12 out of 100,000 in the US, a 20 percent (12 divided by 15) difference. (Or is it that people have a 25% higher chance of dying of prostate cancer in the UK, since 15 divided by 12 is 1.25?). It's odd that the rates are given as "people" who die of prostate cancer, including men and women, since only men have prostates, I would expect to see those rates given in X out of a 100,000 men.

Somehow, Mr. Robinson adds 12 and 15, and comes up with "25 men out of 100,000 die of prostate cancer each year in both countries." He guesses that Mayor Guilani "didn't really care" whether his statistics are correct. Either Mr. Robinson's math is bad, or he "didn't really care" whether his readers to assumed that that's 25 in the US and 25 in the UK.

Since I'm pro-life, I'm concerned about the possibility that Rudy Guiliani may be the next Republican candidate for President. The reason that I tend to vote Republican is because of the Republican Party Platform is pro-life.

However, I am also very concerned about the risk that Government insurance and control of medicine would bring.

While it's true that the NHS doesn't screen nearly as many men as our US docs, that hardly seems an argument for adopting the finance system of the former. Which system do you want: one that gives a 99% survival rate or one that gives 74% ?

Texas has funds for SCHIP without Federal increase

Threats to the contrary, the Houston Chronicle has picked up on the fact that Texas has enough Federal funds to continue CHIP in our State for "at least a year," even with the expansions and improvements passed by the 80th Legislature earlier this year.

And in spite of the President's veto.


This news was also posted at the Texas Health and Human Services CHIP website earlier this week:

The state is closely watching federal action on CHIP, but no immediate changes are expected in the Texas program. The state has sufficient federal funding available to maintain the Texas program, including the recent changes authorized by the 80th Texas Legislature.

SCHIP goes on, in spite of veto

Let's get this straight: SCHIP will not cease to be because of the President's veto.

Last month, we read that Congress had passed a 16 week extension of SCHIP and that the President would veto the SCHIP bill if Congress went ahead with their planned expansion to nearly double the funding.

The SCHIP bill that was passed was an ideological stunt that included re-definition of prenatal pregnancy care (to medical treatment of the pregnant woman - which would include abortion in some states, possibly all) and which increased the funding way beyond that needed to continue coverage for the 6.5 million children currently eligible.

Beyond raising the funding level without a clear cut plan for raising funds (possible increased cigarette taxes while counting the lapse of tax cuts of a few years ago), the Bill would have forced States such as Texas, where the cost of living is lower, to subsidize States such as New Jersey and New York, where proponents say that a family of 4 can't live on $80,000+ a year. As it is, Texas does not spend all of our allocated SCHIP and Medicaid money - that money is used to reward the big spender States. (Do we know how much of that reward is responsible for the high cost of living in those States?)

The President and Congress will now come up with a more reasonable plan, probably somewhere between the $5 Billion dollar over 5 years that the President proposed and the $35 Billion dollar expansion that Congress passed.

Late note:
The Democrats are postponing the vote to overturn the veto for 2 more weeks:

But the Democratic-led Congress put off an override vote for about two weeks, to give them more time to put pressure on GOP lawmakers who they think are politically vulnerable. A union-led organization said it would spend more than $3 million trying to influence the outcome.

"It's going to be a hard vote for Republicans," said House Speaker Nancy Pelosi, D-Calif.

The Senate passed the five-year expansion of the program last week on a vote of 67-29, just above the two-thirds margin needed to override a veto, but the House tally of 265-159 was 25 votes short of that mark.

Bush advisers said they remain convinced that they can secure an extension of the 10-year-old program with a less expensive price tag, saying they hope to soon open negotiations. But if the veto stands, Democrats said, they will reapprove the measure without significant changes and send it back to the White House, forcing the GOP to go on record again as opposing expansion of the program.

Courts force 14 States to pay for elective abortions

Here's an interesting fact: of the 17 states that use their own Medicaid funds to cover elective abortions, 14 of them were forced to do so by the courts. (Georgia may be the next one.)

The "Hyde Amendment" has been added to Federal health care funding bills since 1976. Those who support abortion on demand (such as the ACLU, the Center for American Progress, and, of course, the National Abortion Federation and Planned Parenthood) are constantly calling for its "repeal," although in fact, the language would just be dropped from that year's appropriations bill.

Reminds me of the comment of one of the judges in a "right to die" case: The founding fathers did not intend for the important matters to be decided by the courts and only the trivial matters determined by the legislators.

Buzz on SCHIP - crisis interrupted or delayed

Do we want health insurance for everyone or do we want government health insurance for everyone? The current system increases the chances that employee coverage for children will decrease, that more gaps will occur because of changes in jobs and the delays inherent in qualifying for government assistance. A simple flat tax deduction for health insurance would cure these ills for everyone.


Where's the fun in taking away the deadline? The House has passed a "stop gap" bill to allow the current program and current funding to continue to November.

Bloggers and pundits are waiting breathlessly to see whether the President vetoes the House's $35 Billion SCHIP expansion. Many of them, like the Wired and Bioethics.net posts are thinly veiled political hits against the current administration, ignoring the fact that President Bush proposed an instant "coverage" solution. (Some are in-your-face attacks)

On the other hand, the Wall Street Journal (subscription) notes that the House version is much more of a compromise than expected:

In some ways, after difficult negotiations, the bill turned out to be an unusual example of cooperation. In talks with two Senate Republicans, House Democrats compromised. They cut new spending from $50 billion to $35 billion, gave up an effort to cover legal immigrants and young adults, and dropped cuts to private health insurers operating in Medicare.

The final deal includes many nods to Republicans -- though most Republicans in the House and Senate oppose it as an irresponsible expansion of government spending. It reduces federal funding for states that enroll children from families with incomes above about $60,000 a year for a family of four; it bars the federal government from allowing any more states to use CHIP funds to cover parents; and it phases out coverage of childless adults that some states include in CHIP.

To tilt the program toward poorer children, the bill calls for states not meeting enrollment benchmarks for the lowest income children by October 2010 to give up CHIP funds for enrollees above 300% of the poverty level.(emphasis mine)

More on Clinton Health Plan

After my review about some of the news coverage of Hillary Clinton's proposed government healthcare plan, I did some more digging. The Kaisernetwork.org review is here. A Wall Street Journal editorial is here.

The proposed Clinton plan mandates coverage and depends on 1/3 of its revenue from "$35 billion in savings to the government through a more efficient health system." (I wonder who will be considered less "efficient" - doctors or very sick patients?) And mandates that insurance premiums remain below a certain percentage of household income and that tax rates increase in households above $250,000.

All of which, the history of HMO's, capitated plans, and most especially government funding tells us, will result in restrictions in services, long waiting times, and less convenience combined with loud demands for more.

I know it seems a cliché, but how does government "efficiency" work at the Post Office? Fed-ex, UPS and DHL don't have nearly the restrictions medical care does: They charge according to weight, size and distance, but the customer and the recipient decide the contents of the package and the destination. I've never heard of Fed-Ex telling a customer that their package wasn't necessary or couldn't be moved because some Ph.D. (Doctor of Packing handling) had set a formulary - or that they'll take the package 100 miles and no farther. The biggest difference is convenience and the variety of options offered. Although they are able to compete financially and functionally with the US Postal Service, the lines aren't as long and the system is built to handle the unusual. The unusual is a large part of our business in Family Medicine.

The US First Class stamp is great for letters that don't need to be delivered for a day or two. Maybe the government should cover preventive health and let insurance cover sick people.

Mandates don't guarantee coverage. In Texas, we have to show our insurance card when we register the car, get our license renewed and each year when we have the car inspected. The uninsured rate is estimated to be around 24% (anywhere from 20 to 60%, according to the numbers of tickets issued in the big cities). In Colorado, it may be as high as 35%. (More here.) To compensate, Texas will soon begin correlating driver's licenses, car registration and insurance by a data bank accessible to the police car behind you in traffic. Wait 'till Bubba catches wind of this.


A little bit for everyone from the first dollar that cuts off above a certain level is dangerous. I know Medicare eligible patients who had great drug benefits through their retirement plans. They were forced to go to one of the "donut hole" plans, and now pay more out of pocket than before. We now have a good indication that the "donut hole" in the Medicare Part D drug plan leads to an increase in hospitalizations.

However, while researching all this, I did read about one plan that seemed to make sense to me. I've copied, pasted, and changed the name to "the Plan."

The Plan Gives All Americans The Same Tax Breaks For Health Insurance And Helps States Make Affordable Private Health Insurance Available To Their Citizens.

1. The Plan Will Help More Americans Afford Health Insurance By Reforming The Tax Code With A Standard Deduction For Health Insurance – Like The Standard Deduction For Dependents. The primary goal is to make health insurance more affordable, allowing more Americans to purchase coverage. The Plan levels the playing field for Americans who purchase health insurance on their own rather than through their employers, providing a substantial tax benefit for all those who now have health insurance purchased on the individual market. It also lowers taxes for all currently uninsured Americans who decide to purchase health insurance – making insurance more affordable and providing a significant incentive to all working Americans to purchase coverage, thereby reducing the number of uninsured Americans.

* Under the Plan, Families With Health Insurance Will Not Pay Income Or Payroll Taxes On The First $15,000 In Compensation And Singles Will Not Pay Income Or Payroll Taxes On The First $7,500.
o At the same time, health insurance would be considered taxable income. This is a change for those who now have health insurance through their jobs.
o The Plan will result in lower taxes for about 80 percent of employer-provided policies.
o Those with more generous policies (20 percent) will have the option to adjust their compensation to have lower premiums and higher wages to offset the tax change.

2. The Affordable Choices Initiative Will Help States Make Basic Private Health Insurance Available And Will Provide Additional Help To Americans Who Cannot Afford Insurance Or Who Have Persistently High Medical Expenses. For States that provide their citizens with access to basic, affordable private health insurance, the Plan's Affordable Choices Initiative will direct Federal funding to assist States in helping their poor and hard-to-insure citizens afford private insurance. By allocating current Federal health care funding more effectively, the Plan accomplishes this goal without creating a new Federal entitlement or new Federal spending.

There's no list of covered benefits, no mandates. However, each family would choose how much and what kind of coverage to buy. The current system of larger tax breaks to employers for more expensive health insurance and smaller breaks for less expensive coverage would disappear. Tax breaks for insurance would no longer be tied exclusively to a given job. Government subsidies would only be necessary for the indigent and those "hard-to-insure."

The plan was proposed by President Bush in his 2007 State of the Union address and is outlined here.